Provider Demographics
NPI:1376547059
Name:CARRASQUILLO, HIRAM (MD)
Entity Type:Individual
Prefix:
First Name:HIRAM
Middle Name:
Last Name:CARRASQUILLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 SAN MARCO BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-8566
Mailing Address - Country:US
Mailing Address - Phone:904-202-1032
Mailing Address - Fax:904-858-6475
Practice Address - Street 1:1325 SAN MARCO BLVD STE 200
Practice Address - Street 2:CREDENTIALING DEPARTMENT
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8566
Practice Address - Country:US
Practice Address - Phone:904-346-3465
Practice Address - Fax:904-858-6475
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME67033207X00000X, 207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL376097900Medicaid
FL376097900Medicaid
FL26251ZMedicare PIN